Menopause Role in Heart Risk Disputed

Action Points

Explain that heart disease mortality in women increased with age but menopause did not appear to play a role.

Point out that, in contrast, men had an accelerated risk of dying of heart disease at younger adult ages, but mortality plateaued at middle and older ages.

Heart disease mortality in women increased with age but menopause did not appear to play a role, a 50-year review of mortality trends showed, disputing the belief that premenopausal hormones protect women from heart disease, investigators said.

No spike in heart disease mortality occurred at menopausal ages in women from three large birth cohorts from the U.S., England, and Wales. Instead, mortality increased steadily across all age groups of adult women.

In contrast, men had an accelerated risk of dying of heart disease at younger adult ages, but mortality plateaued at middle and older ages, as reported online in BMJ.

"Our data show there is no big shift toward higher fatal heart attack rates after menopause," Dhananjay Vaidya, PhD, of Johns Hopkins, said in a statement.

"What we believe is going on is that the cells of the heart and arteries are aging like every other tissue in the body, and that is why we see more and more heart attacks every year as women age. Aging itself is an adequate explanation and the arrival of menopause with its altered hormonal impact does not seem to play a role."

The findings have clear implications for managing heart disease risk in women, Vaidya and co-authors believe.

"Efforts to improve cardiac health in women should focus on lifetime risk rather than risk only after menopause," they wrote in conclusion.

Scientists have long attributed the delayed onset of ischemic heart disease in women compared with its appearance in men to a protective effect of premenopausal hormones. However, that belief has little or no supporting evidence from epidemiologic or clinical studies, the authors noted in their introduction.

Mortality from heart disease does increase with age, but studies have shown no acceleration of mortality in women during or after menopause, they continued. Men's more rapid acceleration of ischemic heart disease mortality at younger ages could just as likely reflect a failure of vascular repair mechanisms in men, as opposed to hormonal protection in women.

In an effort to sort out the conflict between clinical perceptions and data, Vaidya and colleagues analyzed data on three birth cohorts, beginning in 1916 and ending in 1945. They determined the population of each birth cohort on the basis of census data from 1950 and 2000.

The authors analyzed ischemic heart disease mortality over time as the three birth cohorts aged. None of the cohorts had a substantial upswing in the slope of heart disease log-mortality curves for women around the time of menopause. Rather, the data showed a log-linear increase in overall mortality across all ages.

Among men, the log-linear increase in mortality continued until about age 45, and then remained stable into older ages.

Consistent with knowledge that men develop heart disease at an earlier age, the ischemic heart disease mortality curve for men increased by 30.3% a year until age 45, slowing significantly to 5.2% thereafter (P=0.042). The overall change averaged 5.8%

Among women, ischemic heart disease mortality increased by 7.9% overall and did not differ significantly before, during, or after menopause (P=0.43).

The data are consistent with the authors' proposed biologic explanation that fatal ischemic heart disease events result from "loss of reparative reserve."

"Acceleration in male heart disease mortality at younger ages could explain sex differences rather than any menopausal changes in women," the authors wrote.

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